264

HEART DISEASES

[VOL. vj

Signs of
distension

Signs of

congestive

failure

Position of

inspiratory waning or even obliteration of the pulse is easily observed
(pulsus paradoxus, or Griesinger-Kussmaul pulse).
Since the heart occupies a position more or less fixed in the chest, and

since fluid formed must be
accommodated somewhere,
it necessarily accumulates
and bulges laterally and back-
wards on each side. The dis-
tension is greatest on the left
side, giving rise to signs de-
scribed by Ewart in 1896—a
zone of dullness with tubular
breath sounds extending from
the angle of the left scapula
downwards and inwards to-
wards the lower dorsal verte-
brae. Whether these signs
are produced by mechanical
pressure on the lung, by
pressure on the left bronchus
producing pulmonary col-
lapse, or by any other
mechanism is immaterial to
the problem of diagnosis. In
addition to these signs, there
are very commonly reduction
of movement, dullness on
percussion, and weak breath
sounds at both bases, due,
as may be demonstrated by
X-rays, to bilateral effusions
into the pleural cavities.

While the local evidences of
fluid in the pericardium are
becoming more obvious, the
FIG. 38.—Acute rheumatic pericarditis, (a) Show- patient is becoming more
ing pericardia! and bilateral pleural effusions; distressed. Signs of concest-
(6) six weeks later, showing heart of normal r •*

size and contour, disappearance of effusions, 1V® failure appear — cyan-
and lower position of diaphragm osis, engorgement of cervical

veins, oedema of dependent

parts, and enlargement of the liver. This hepatic enlargement is also
due to local pressure by fluid upon the hepatic veins opening into the
inferior vena cava.

It has been stated erroneously that the liver is displaced downwards by
the accumulation of fluid in the pericardium; it is not difficult to demon-
strate by serial X-rays taken during effusion and on recovery that the
diaphragm actually occupies a higher position during the phase of